September 17, 2009 | Mark Paradies

Did Floor Mat Kill 4?

Here’s a difficult investigation – how would you find the root cause(s)?

Four people were killed when the loaner Lexus 350 crashed and burst into flames. USA Today reports that:

California Highway Patrol Officer Mark Saylor, 45, and three others were killed Aug. 28 on State Route 125 in Santee, a town near San Diego. The runaway car was doing more than 120 mph when it hit a sport-utility vehicle, launched off an embankment, rolled several times and burst into flames.

They also report:

Lastrella called police about a minute before the crash to say the vehicle had no brakes and the accelerator was stuck.

The call ends with someone telling people in the car to hold on and pray, followed by a woman’s scream.

The family was in a 2009 Lexus ES 350 that was loaned by a dealer, Bob Baker Lexus El Cajon, while their own vehicle was being serviced.

Investigators with the National Highway Traffic Safety Administration have determined that a rubber all-weather floor mat found in the wreckage was slightly longer than the mat that belonged in the vehicle.

The NTSB Investigator said:

We don’t know if the all-weather floor mat was properly secured or not. We do know that it was a floor mat from a different Lexus.

As an investigator, how can you provide 100% assurance that you have found the root causes of this accident?

Looks like a SnapCharT® might help with the investigation (what is assumptions and what is known).

Root Cause Analysis
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